Basic Information
| Provider Information | |||||||||
| NPI: | 1013375203 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MT AUBURN PROFESSIONAL SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BELMONT MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 ARSENAL MARKET PL | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024725018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176731851 | ||||||||
| FaxNumber: | 6174995579 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 CONCORD AVE | ||||||||
| Address2: | SUITE 4100 | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021381040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178648822 | ||||||||
| FaxNumber: | 6175475367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2016 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6174995530 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LA0401X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Addiction Medicine | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.